Antibiotic Use in Outpatient Settings

Health experts create national targets to reduce unnecessary antibiotic prescriptions

Report
Projects: Antibiotic Resistance
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Antibiotic Use in Outpatient Settings

Overview

The use and misuse of antibiotics is a major contributor to the development of antibiotic-resistant bacteria. These drugs should be used only to treat bacterial infections and, when needed, the right antibiotic should be prescribed at the most appropriate dose and duration. Yet antibiotics are often prescribed inappropriately across health care settings in the United States. Antibiotic stewardship efforts, which aim to ensure that these drugs are prescribed appropriately, are critical for combating the public health threat posed by antibiotic-resistant pathogens. To effectively implement and evaluate stewardship efforts, it is essential to first understand current antibiotic prescribing patterns.

Antibiotic use in outpatient health care settings, such as primary care offices and emergency rooms, represents the majority of dollars spent on antibiotics for human health care in the United States.1 Beginning in 2015, The Pew Charitable Trusts convened a panel of experts, including representatives from the Centers for Disease Control and Prevention (CDC) and other public health and medical experts to analyze current outpatient antibiotic prescribing habits in the United States, determine targets for reducing inappropriate prescribing, and identify steps needed to reach these targets.

Key findings from this analysis are:

  • Antibiotics should be prescribed only when a bacterial infection is known or suspected. Approximately 13 percent of all outpatient office visits in the United States, or about 154 million visits annually, result in an antibiotic prescription; about 30 percent of these, or some 47 million prescriptions, are unnecessary.
  • 44 percent of outpatient antibiotic prescriptions are written to treat patients with acute respiratory conditions, such as sinus infections, middle ear infections, pharyngitis, viral upper respiratory infections (i.e., the “common cold”), bronchitis, bronchiolitis, asthma, allergies, influenza, and pneumonia. Half of these prescriptions are unnecessary, since many are viral illnesses or other conditions that do not respond to antibiotics.
  • In 2015, the White House released a national action plan for combating antibiotic resistance that included the goal of reducing inappropriate outpatient antibiotic use by 50 percent by 2020.2 Based on the panel’s estimate of unnecessary prescribing, this goal would be reached by reducing outpatient antibiotic use by 15 percent overall, which would result in approximately 23 million fewer antibiotics prescribed annually by 2020.

This report is the first in a series evaluating current antibiotic use in the United States and establishing national targets for improved prescribing practices in different health care settings.

This report is the first in a series evaluating current antibiotic use in the United States and establishing national targets for improved prescribing practices in different health care settings.

In addition to these findings, the expert panel discussed the importance of increased stewardship activities to ensure that the United States reaches the goal laid out in the 2015 national action plan. There is no one-size-fits-all stewardship program that practitioners can implement in their facilities. However, a number of interventions have been shown to be effective at improving prescribing habits, such as providing clinicians with individualized antibiotic prescribing feedback.

Since no single agency or organization oversees antibiotic use in outpatient facilities across the country, implementing stewardship programs nationwide will be a complex undertaking. A diverse group of stakeholders will need to take coordinated and sustained action to provide the resources and expertise necessary to expand stewardship efforts. Below is a sampling of roles that stakeholders could play in reducing inappropriate outpatient antibiotic use:

  • Individual outpatient health care providers can evaluate their own prescribing habits as well as implement stewardship activities in their practices.
  • Health systems can provide expertise and resources to offices within their network to aid in stewardship implementation.
  • Health plans can assist in data collection and analysis—evaluating the antibiotic prescribing habits of their providers and providing feedback highlighting potential areas for improvement.
  • State and local health agencies can help provide outpatient facilities with information on best practices for implementing antibiotic stewardship programs, and help develop regional partnerships between various health care stakeholders, such as providers, health plans, and health systems, to better coordinate stewardship activities.
  • Federal agencies can track antibiotic prescribing at the national level, identifying areas for further improvement and providing technical assistance to stakeholders interested in implementing stewardship efforts of their own.
  • Organizations that develop standards to assess the quality of health care services can develop metrics to assess the antibiotic prescribing habits of health care providers.
  • Health care professional societies can provide expert guidance to their members on appropriate antibiotic prescribing and incorporating diagnostics to aid in prescribing decision-making.

BACKGROUND

Antibiotics are essential to the practice of modern medicine—from treating common infections to enabling lifesaving procedures such as organ transplantation. However, the emergence and spread of antibiotic-resistant bacteria threaten the effectiveness of these critical therapies. According to the World Health Organization, high rates of resistance in common bacteria are being seen worldwide.3 In the United States, drug-resistant bacteria are responsible for at least 2 million infections each year, resulting in an estimated 23,000 deaths.4

Infections caused by multidrug-resistant bacteria are becoming increasingly common. A 2011 survey of U.S. infectious disease physicians found that over 60 percent of respondents had treated a patient with an infection resistant to all available antibiotics.5 Of particular concern is the spread of carbapenem-resistant Enterobacteriaceae (CRE), due to its resistance to many, if not all, available therapies and its high mortality rate once infecting the bloodstream.6 In 2001, only one state reported a case of CRE; as of early 2015, only two states had not reported one.7

Importance of improved antibiotic stewardship

All antibiotic use, whether appropriate or not, carries a risk of contributing to the development of antibiotic resistance. To minimize this threat and preserve the effectiveness of these important drugs, antibiotics should be used judiciously and prescribed only when recommended. However, much antibiotic use is unnecessary or inappropriate.8 Over 60 percent of antibiotic expenditures in the United States occur in outpatient settings where patients are seen for many conditions that do not warrant antibiotic use, such as acute bronchitis.9 Antibiotic stewardship efforts aim to ensure that these drugs are used only when indicated (i.e., for a known or suspected bacterial infection) and prescribed at the right dose and duration of therapy. Such programs are critical to limiting the development of antibiotic resistance.

In addition to the importance of antibiotic stewardship in minimizing the threat of resistance, reducing inappropriate antibiotic use can also improve patient safety. Exposure to antibiotics increases a patient’s risk of an infection caused by Clostridium difficile, which can cause sometimes life-threatening diarrhea. There were nearly 500,000 estimated cases of C. difficile infection in the United States in 2011, which resulted in approximately 15,000 deaths.10 Antibiotics also carry the risk of adverse drug events, including drug interactions, allergic reactions ranging from minor rashes to life-threatening responses, and other side effects. It is estimated that antibiotic-related adverse events result in more than 140,000 emergency room visits a year.11

ENDNOTES

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  2. The White House, National Action Plan for Combating Antibiotic-Resistant Bacteria, March 2015, accessed July 27, 2015, https://www.whitehouse.gov/sites/default/files/docs/national_action_plan_for_combating_antibotic-resistant_bacteria.pdf.
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  18. No reduction target was set for adults 65 and older as there were not enough suppurative middle ear infection visits resulting in antibiotic prescriptions to make a reliable estimate.
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  22. No reduction target was set for adults 65 and older as there were not enough pharyngitis visits resulting in antibiotic prescriptions to make a reliable estimate.
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